The Affordable Care Act (ACA) will dramatically improve the nongroup and small group health insurance markets for everyone in them, including the high-risk population. But insurance reforms, guided by requirements for minimum or "essential health benefits," insurance plan actuarial value and other tools provided by the ACA, are and will remain a work in progress. This analysis suggests the way these tools-working together and reevaluated over time-can most effectively ensure that ACA implementation progresses toward the goals of adequate and affordable insurance protection, especially for the highest-need, highest cost patients.